The Physician Within Me: Surgery Amidst Conversations

Performing brain surgery while a patient remains awake demonstrates the peak capabilities of Vietnamese physicians and medical staff in specialized, complex neurology.

With over 20 years in neurosurgery, Assoc. Prof. Trương Thanh Tình, MD, PhD, Head of the Neurosurgery Department at University of Medicine and Pharmacy Hospital Ho Chi Minh City, still remembers the suspense of the first successful awake craniotomy performed by the team. This is not only an advanced technique in modern medicine but also a race against time to preserve a patient's motor function, speech, and future.

1. Special Surgeries

A recent case performed by Dr. Tình and his colleagues at University of Medicine and Pharmacy Hospital Ho Chi Minh City was an awake craniotomy—an advanced method in treating brain tumors and lesions, particularly those located in critical functional areas. A 12-year-old pediatric patient had suffered from persistent headaches for two months, accompanied by transient weakness on one side of the body and a brief loss of consciousness. Upon examination at University of Medicine and Pharmacy Hospital Ho Chi Minh City, doctors discovered a large brain tumor located directly in a critical functional zone associated with movement and speech. This is an exceptionally sensitive location where any intervention carries the risk of long-term sequelae, impacting the patient's mobility, communication, and quality of life if not strictly controlled.

Facing this challenge, the team chose an awake craniotomy—an intensive neurosurgical technique typically indicated for brain lesions situated near critical functional regions—instead of standard general anesthesia. Unlike conventional brain surgery, the patient is not kept under deep general anesthesia.

Assoc. Prof. Trương Thanh Tình, MD, PhD, Head of the Neurosurgery Department at University of Medicine and Pharmacy Hospital Ho Chi Minh City (second from the left), during a surgery

After opening the skull, the patient remains awake, without an endotracheal tube, and continuously interacts with the doctor. The operating room at that moment houses not only the surgeon but also multiple anesthesiologists, neurologists, and intraoperative neurophysiological monitoring specialists. Each person plays a distinct role in "guarding" the vital functions of the brain. The patient is asked to count numbers, name objects, perform hand movements, flex and extend wrists, or touch fingertips. These seemingly simple tasks serve as a "living map" helping doctors identify safe brain zones to approach the lesion. "If the patient suddenly experiences hand weakness, speech difficulty, or fails to name an object correctly during surgery, we know we have just touched a functional area and must change our approach immediately," Dr. Tình explained.

Dr. Tình recounted that previously, the hospital also successfully performed an awake surgery for a young man in his early twenties with a brain arteriovenous malformation located right in the motor region. The patient was admitted due to prolonged headaches. Imaging diagnostics revealed the lesion was situated right next to the area controlling limb movement. Operating via conventional methods carried a very high risk of hemiplegia. Because the patient was very young and unmarried, leaving behind sequelae would completely alter his future, prompting the team to weigh their options carefully. Following the surgery, the young man only experienced mild weakness in fine wrist and finger movements with a muscle strength of about 4/5, while the primary motor functions of his limbs were preserved. The patient was discharged after three days, conscious, speaking normally, and recovering well.

2. A "Detour" Inside the Brain

According to Dr. Tình, an awake craniotomy allows patients to have their speech and motor functions directly assessed right during the surgical procedure. This helps surgeons determine safe boundaries when dissecting tumors, recognize early risks of affecting brain functions to adjust maneuvers promptly, and thereby minimize damage to vital neural pathways.

Special brain surgeries like this are likened to navigating a "labyrinth" inside the brain. The team must find a way to reach the lesion without encroaching upon motor, speech, and sensory control areas. "There are zones that must absolutely not be touched. We take a different route, dissecting around the edges first before handling the last remaining attached portion. Removing the lesion then becomes much safer," he stated.

Assoc. Prof. Trương Thanh Tình, MD, PhD, visiting the pediatric patient after surgery

Dr. Tình noted that the greatest challenge in neurosurgery today is not merely removing a tumor or vascular malformation, but removing the maximum amount of the lesion while ensuring the patient can still speak, walk, and return to normal life. Especially with malignant or invasive brain tumors, the boundary between diseased and healthy tissue is very fragile. Many tumor cells have infiltrated normal brain tissue beyond the naked eye's visibility. "At that point, the surgeon must decide whether to excise more widely or stop. Removing too much can cause the patient to become weak, paralyzed, or lose speech. Therefore, awake surgery combined with intraoperative neuro-monitoring is the key to balancing disease treatment and functional preservation," Dr. Tình added.

3. Dedication to the Community

Assoc. Prof. Trương Thanh Tình, MD, PhD, shared that he chose medicine with a simple thought: saving lives with his own hands and knowledge. After years of study, he pursued neurosurgery—a specialty considered the "peak of pressure" in surgery, where a single minor mistake can leave a patient paralyzed, mute, or completely change their life.

In his early years in the profession, he witnessed many young patients bearing brain tumors or vascular malformations who had to relearn how to walk and speak from scratch after surgery. This drove his aspiration for a method that could completely remove lesions while maximally preserving brain function. "Brain damage is not as frightening as a patient losing the ability to live normally after surgery," he shared.

"I am glad that Vietnamese patients can now access advanced techniques on par with regional and global standards. With our people, technology, and aspirations, we are fully capable of achieving this," Assoc. Prof. Trương Thanh Tình, MD, PhD, shared.

Few know that behind surgeries lasting many hours lies immense pressure on the surgeon's shoulders. Assoc. Prof. Trương Thanh Tình, MD, PhD, recalled a case involving a teacher in his 40s who had undergone brain surgery twice before, but the tumor continued to recur right in the motor region. His wife was also a teacher, so their only wish was for her husband to still be able to stand at the lectern after surgery. "What I remember most is the family's very simple desire: ensuring the patient could still teach after treatment," he recalled. That day's awake surgery succeeded. The teacher subsequently underwent radiotherapy and chemotherapy and continues to teach normally today.

These special brain surgeries also serve as motivation for Dr. Tình and his colleagues to continue pursuing difficult techniques such as epilepsy surgery, neuromodulation, and minimally invasive brain surgery. To date, Dr. Tình and his colleagues at University of Medicine and Pharmacy Hospital Ho Chi Minh City have successfully performed 13 awake brain surgeries. For this talented neurosurgical specialist, the greatest reward after each surgery is not fame or praise, but the moment a patient can walk on their own, talk to their loved ones, and resume their normal lives.

4. Bringing Global Excellence Back Home

According to Assoc. Prof. Trương Thanh Tình, MD, PhD, Vietnamese medicine is advancing rapidly in the field of neurosurgery. The department currently utilizes microscopes integrated with smart technology, 3D imaging, and surgical navigation systems.

Assoc. Prof. Trương Thanh Tình, MD, PhD, participating in international scientific reporting events

He also collaborates with many international experts, including specialists from Singapore, France, Taiwan (China), Australia, Malaysia, and more, who assist in evaluating speech and motor functions during awake surgeries and epilepsy procedures.